Clinically, paediatric dental general anaesthetics have evolved over the years, but unfortunately there has not been a decline in the need for them.
The 2015 Royal College of Surgeons "Report on the state of Children's Oral Health" shows that there was a 14 per cent increase in the numbers of dental general anaesthetics, and procedures undertaken from 2010/2011 to 2013/2014 in the five to nine year-old age group.
Over 25,000 dental general anaesthetics were performed as compared to the next highest, tonsillectomies at 11,500 during this 2013/2014 time period.
Dental general anaesthetics are the most common cause for admittance to hospital in children for a GA.
The zero to four year-old age group shows a shocking 24 per cent increase in the number of extractions again during the same time period.
We are all aware that dental decay is a preventable disease and even with the third edition of "Delivering Better Oral Health an Evidence Based toolkit for Prevention" Public Health England, but it feels that this message is not getting heard.
Dental decay in children is a significant factor in their general health and wellbeing, as measured by various quality of life indicators.
Are GAs really still necessary?
Despite the use of various behaviour management techniques and inhalation sedation, there is still a group of children who are very anxious, pre-co-operative, and those who have a limited understanding, and these patients often cannot be treated in a conventional setting.
This is why this method of care is still being provided and if anything, we seem to be experiencing an increase in demand for our services.
The background and history of where we are at with GAs gives an insight into how the process has
progressed from even 30 years ago when a child sat in an upright dental chair and had a "whiff of gas", and the dentist was told, " ...be quick with those extractions!" by the anaesthetist.
The care of the child, family, and carers by the nursing team, comprehensive pain control and explaining to all involved what is going to happen helps reduce the stress for all. The roles of the dental and anaesthetic teams are relatively small within this whole process, which is overseen by a nursing team.
The issues of shared airways must always be considered, what we need, and what the anaesthetist needs for the safety of the child, so we are on common ground.
So whether it is a laryngeal mask, north or south facing, oral intubation or nasal intubation, it is still a compromised clinical environment. Some clinicians find this challenging to accept, and that what they can provide is ultimately, always, a compromise.
When providing care this way, conventional treatment planning has to be adapted. This is not the time for "let's try and see if it works, and then bring them back in two weeks".
Definitive evidence-based treatment planning that is actually going to work must be made in tight time constraints with other issues/demands on the clinician at the same time.
We know that repeat GAs should be avoided if at all possible, so making those sometimes difficult decisions, requires experience, confidence, and the support of colleagues and peers.
Are GAs 'value for money'?
Going back to the issue of repeat GAs and the pressure on existing GA sessions brings us on to value for money/ effectiveness of what we are doing, particularly in a financially-strapped NHS.
Resources are ever scarce. So we need to make sure that what we are doing shows value for money, and that these services are essential, for some patients.
In some areas there is the constraint of extraction-only lists, so that more patients can be seen. This is a difficult clinical decision to make, if restorative care is also needed, and presumably for commissioners, it's also a difficult decision about how resources can be best directed to those who are most in need of it.
As professionals, we always strive to do what is best for our patients, within the financial boundaries set for us by the NHS.
Want to find out more?
Stepping back from our day-to-day activity and reflecting on what, and why we do this, and what the benefits are to the patients and society as a whole, is what our Community Dental Service General Anaesthesia Study Days in January 2018 will be about, and hopefully will give you some useful insights for your practice.
So whether you are a GDP who initially sees a child, and then refers to secondary care, or a provider in secondary care, the issue of paediatric dental general anaesthetics is never an easy decision, and how we can improve care for those who need it, how we can encourage prevention whenever possible, are things every dentists should have at the forefront of their minds.
Specialist in Special Care Dentistry